Oyekanmi et al. BMC Research Notes 2012, 5:267
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RESEARCH ARTICLE
Open Access
Demographic and clinical correlates of sexual
dysfunction among Nigerian male outpatients on
conventional antipsychotic medications
Aina Kikelomo Oyekanmi1, Adegoke Oloruntoba Adelufosi2*, Olukayode Abayomi2 and
Timothy Olaolu Adebowale1
Abstract
Background: In psychotic disorders, early intervention with antipsychotic medications increases the likelihood of
favourable long-term course. However, the pharmacologic management especially with conventional antipsychotic
medications is complicated by a high rate of adverse effects including sexual dysfunction. This study aims to
determine the demographic and clinical factors associated with sexual dysfunction among male psychiatric
outpatients on conventional antipsychotic medications in South-western Nigeria.
Methods: Two hundred and seventy five consecutive male outpatients with psychotic disorders on conventional
antipsychotic medications were interviewed. Data was collected on demographic characteristics, illness-related and
medication-related variables. Illness severity was assessed with the Brief psychiatric rating scale. The International
Index of Erectile Function questionnaire was used to assess for sexual dysfunctions.
Results: A total of 111 (40.4%) respondents had one or more forms of sexual dysfunction. Sexual desire dysfunction
was present in 47 (17.1%) of respondents, erectile dysfunction in 95 (34.5%), orgasmic dysfunctions in 51 (18.5%),
intercourse dissatisfaction in 72 (26.2%) and overall dissatisfaction in 64 (23.3%). Sexual dysfunction was significantly
associated with employment status, age, marital status, haloperidol use, medication dosage, and presence of
psychopathology. Unemployment was the only significant independent correlate of sexual dysfunction, with
unemployed respondents twice more likely to have sexual dysfunction compared with those employed
(Wald = 3.865, Odds Ratio = 2.033, 95% confidence interval = 1.002 - 4.124, p = 0.049).
Conclusions: The high prevalence of sexual dysfunction found in this study suggests a need among clinicians for
increased awareness and recognition of the sexual side effects in patients taking conventional antipsychotic
medications. This knowledge should guide conventional antipsychotic medication prescription in the at-risk
population to improve treatment adherence.
Keywords: Sexual dysfunction, Conventional antipsychotics, Schizophrenia
Background
Sexual dysfunction is commonly associated with the
pharmacologic management of psychotic illnesses especially conventional antipsychotic medications [1-3]. This
is further complicated by the effects of major psychotic
illness itself on sexual functioning, among which are
reduced libido, decreased sexual performance and satisfaction [4].
* Correspondence: [email protected]
2
Ladoke Akintola University Teaching Hospital, Ogbomoso, Oyo State, Nigeria
Full list of author information is available at the end of the article
Previous studies showed that sexual dysfunction occurred in as many as 60% of outpatients with schizophrenia [5-7]. Sexual adverse effects have been reported
in up to 45–50% of patients taking conventional antipsychotics and are more likely to be disturbing to men than
women [8-10]. Other authors reported that more than
50% of males on conventional antipsychotics experienced sexual dysfunction [11]. Commonly experienced
sexual side effects in males are poor penile erection,
ejaculatory and orgasmic disturbance [12,13]. Despite
this high rate, complaints about sexual dysfunction are
largely unexplored or ignored by clinicians, or attracted
© 2012 Oyekanmi et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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only vague reassurances resulting in poor medication adherence and quality of life [2,14,15].
There is a paucity of studies on sexual dysfunction in
Nigeria [16]. Many of the available studies were conducted among medical outpatient clinic attendees and
community samples, with findings which cannot be generalized to patients in specific diagnostic groups like
schizophrenia and other psychotic disorders [17,18]. A
recent study by Mosaku & Ukpong [19] conducted among
outpatients attending a psychiatric clinic in Southwest
Nigeria reported a prevalence of 86.5% for erectile dysfunction, with varying prevalences reported for other
forms of sexual dysfunctions. However, aside patients
with schizophrenia, the study included patients diagnosed with other mental illnesses such as depression, bipolar affective disorder, and psychoactive substance
dependence, who may actually have differing patterns
and prevalences of sexual dysfunction. To the best knowledge of the authors, no Nigerian studies have reported
the prevalence and correlates of sexual dysfunction among
patients in a specific diagnostic group like those with
schizophrenia and delusional disorders.
The aim of this study was to determine the prevalence
of sexual dysfunction, associated socio-demographic and
clinical factors among male patients with psychotic disorders on conventional antipsychotic, in Southwestern
Nigeria.
Methods
Study design and setting
This was a descriptive cross sectional survey of sexual
dysfunction among male out-patients with schizophrenia
on conventional antipsychotic medications for at least
six months. The study was carried out at the out-patient
clinic of the Neuropsychiatric Hospital Aro, Abeokuta,
Nigeria between August 2005 and February 2006. The
annual report of the medical records department of the
hospital showed that 3,270 patients with a diagnosis of
schizophrenia attended the outpatient clinic in 2004
(Unpublished data, medical records department). The
hospital has a total capacity of 526 beds and attends to
all patients that come to the hospital through referrals
and those brought by relatives. It has an Emergency/Assessment Unit that provides a 24-hour first-contact and
Emergency services, 7 days of the week while outpatient
clinics are run for follow-up consultations on Mondays,
Tuesdays, Thursdays and Fridays after the first contact
or following discharge from the in-patient care.
Participants
Participants were consecutive male outpatient between
the ages of 18–60 years. Only subjects meeting the ICD10 criteria for schizophrenia and delusional disorders
(F20 – F29) based on information from patients` case
Page 2 of 7
notes’ were included in the study. Patients with clinical
history/record of conditions and medications that may
contribute to sexual dysfunctions viz Diabetes, hypertension, cerebrovascular disorder e.g. stroke, gonadal injury,
endocrine disorder/medications, alcohol dependence, antidepressant medication were excluded from the study (all
patients undergo routine laboratory screening including
fasting/random blood sugar and full physical examination at presentation and regular intervals for any concomitant physical illness at the study center; body weight
and BP checks are also carried out at every visit).
Instruments
The following instruments were administered:
1. A questionnaire drawn up by the researchers
(AKO and TOA) to elicit information on
socio-demographic characteristics of respondents
and their clinical characteristics, such as illness
and medication history.
2. Brief Psychiatric Rating Scale (BPRS) - The BPRS
is a widely used instrument developed by Overall
& Gorham to measure psychotic symptoms and
psychopathology profiles [20]. It is a semi-structured
interview schedule originally comprising 16 items.
Each item is scored on a 7-point scale and produces
sub scores (profiles) for affective, psychotic and
negative symptoms. The 16 items of the original
scale was used in this study to measure current
psychopathological profile of the subjects. The
BPRS has been used by previous researchers in
Nigeria [21]
3. The International Index of Erectile Function
(IIEF) questionnaire - This is a self administered
questionnaire that evaluates male sexual functions.
The IIEF was developed by an International panel
of experts through an extensive review of the
literature and existing questionnaires in addition to
detailed interview of men with sexual dysfunction
and their partners [22]. The IIEF instrument
consists of 15 questions (Q), rated on a scale of 1–5,
with 0 indicating no sexual activity or no attempt.
It has 5 domains: Erectile dysfunction (Q1 – 5, 15),
Orgasmic Function (Q9, 10), Sexual Desire (Q11,
12), Intercourse Satisfaction (Q6 – 8), and Overall
Satisfaction (Q13, 14), each addressing a unique
dimension of sexual function. Total IIEF
questionnaire score ranged from 0–30, with higher
scores indicating better sexual functioning.
Responses to each question are based on a man’s
experience over the past 4 weeks. The IIEF has been
used by previous authors in Nigeria [19] and in their
study, a reliability coefficient (cronbach’s alpha) of
0.921 was obtained.
Oyekanmi et al. BMC Research Notes 2012, 5:267
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All the questionnaires were translated to Yoruba (the
predominant language in the locality of the study) through
the process of back translation.
Page 3 of 7
majority of patients (86.9%) were employed. The patients
were predominantly Christians (62.9%) Table 1.
Clinical characteristics and medication related variables
Procedure
Consecutive male outpatient clinic attenders between
the ages of 18–60 who were married and/or who had
a regular sexual partner and who had fulfilled the ICD-10
criteria for schizophrenia, and delusional disorders
(F20 – F29) at one time or the other based on information from patients` case notes’, and were currently on
conventional antipsychotic medications for at least six
months (including those that still had active or residual
symptoms but not acutely disturbed with gross excitement or disorientation) were included. The interviews
were conducted by AKO and two trained research assistants (resident doctors in psychiatry) in the outpatient
clinic consultation rooms after routine consultation, to
ensure confidentiality. Assistance in completing the questionnaires was provided for the respondents where
necessary.
Ethical considerations
Approval of the Research Ethical Committee of the
Neuropsychiatric Hospital, Aro, Abeokuta, Ogun State,
Nigeria was obtained to carry out the study. This study
complied with the Declaration of Helsinki protocol and
informed verbal consent was obtained from the participants after a detailed explanation of the study.
Data analysis
Statistical Package for Social Sciences (SPSS) version
11.0 for Windows™ was used for data analysis. Most of
the variables were grouped for ease of statistical analysis.
Results were calculated as frequency (%) and mean.
Group differences were determined using Chi-square (χ2)
test for categorical variables and student t-test for continuous variables. Variables that were found to be significantly associated with any form of sexual dysfunction
(independent variables) were then included in a logistic
regression model with presence or absence of sexual
dysfunction as the outcome (dependent variable). Level
of significance was set at p < 0.05.
The majority of patients (87.6%) had a diagnosis of
schizophrenia. The mean age at onset of illness was
27.4 ± 7.4 years. The majority of respondents (42.5%)
had their onset of illness between 15 and 25 years. The
mean (SD) BPRS score was 0.40 (1.2).
The mean duration of conventional antipsychotic medication use was 8.4 ± 2.1 years. One hundred and thirty one
patients (47.6%) had been using medications for more than
35 years. Majority of the patients (55.3%) were taking more
than two conventional antipsychotic at the time of the
study. The mean chlorpromazine equivalent daily medication dose taken by the patients was 462 mg, with the majority (61.8%) being maintained on less than 500 mg
chlorpromazine equivalent daily dose (Table 1).
Prevalence of sexual dysfunction
One or more forms of sexual dysfunction existed among
111 (40.4%) of the respondents. Sexual desire dysfunction was present in 47 (17.1%) of subjects, Erectile dysfunction in 95 (34.5%), Orgasmic Dysfunctions 51 (18.5%),
Intercourse Dissatisfaction 72 (26.2%) and Overall Dissatisfaction 64 (23.3%).
Correlates of sexual dysfunction
The demographic, medication and illness related variables
associated with one or more forms of sexual dysfunction
were: Employment status (sexual desire dysfunction, orgasmic dysfunction, intercourse dissatisfaction and overall dissatisfaction), age group (orgasmic dysfunction),
marital status (overall dissatisfaction), haloperidol use
(erectile dysfunction, orgasmic dysfunction), medication
dose (erectile dysfunction, orgasmic dysfunction, overall
dissatisfaction), any psychopathology on the BPRS (overall dissatisfaction) Table 2.
Independent correlates of sexual dysfunction
Sociodemographic characteristics
Result of the logistic regression analysis showed unemployment as the only independent correlate of sexual
dysfunction, with unemployed respondents twice as likely to have sexual dysfunction as those employed (Wald =
3.865, Odds ratio = 2.033, 95% confidence interval =
1.002 - 4.124, p = 0.049).
Two hundred and seventy nine male outpatients who
met the inclusion criteria were invited to participate in
the study. There were 5 outright refusals, giving a response rate of 98.6%. The data of 275 male outpatients
meeting the inclusion criteria for the study were analysed. Mean age was 39.5 ± 9.4 years, and they were
mainly between 30 and 39 years old (36.4%). Respondents were predominantly married (60.7%) and the
Discussion
This study examined the prevalence and correlates of
sexual dysfunction among Nigerian men with psychotic
illness attending a psychiatric outpatient clinic.
Overall, about 40% of the respondents had at least
one form of sexual dysfunction. This rate of sexual dysfunction is similar to that reported in other previous
Results
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Table 1 Demographic, Clinical and Medication Related
Characteristics of Respondents
Variable
Age
Frequency (%)
18–29 years
44 (16.0)
30–39 years
100 (36.4)
40–49 years
85 (30.9)
50–60 years
46 (16.7)
Mean (SD) years:
39.5 (9.4)
Education
No Formal Education
10 (3.7)
Primary School
84 (30.5)
Secondary School
Tertiary
Single
Married
Marital Status
Employment Status
Religion
71 (25.8)
93 (33.8)
167 (60.7)
Separated
4 (1.5)
Divorced
8 (2.9)
Widowed
3 (1.1)
Employed
239 (86.9)
Unemployed
36 (13.1)
Christian
173 (62.9)
Muslim
101 (36.7)
Traditional Worshipper
<15 yrs
Age at onset of illness
110 (40)
1 (0.4)
6 (2.2)
15–25 yrs
117 (42.5)
26–35 yrs
111 (40.4)
>35
41 (14.9)
Mean (SD): 27.4 (7.4)
Schizophrenia
Diagnosis
Duration of
Antipsychotic
Medication Use
241 (87.7)
Persistent delusional
disorder
1 (0.4)
Acute & transient
psychotic disorder
2 (0.7)
Schizoaffective disorder
2 (0.7)
Unspecified non organic
psychotic disorder
29 (10.5)
<2 yrs
28 (10.2)
2–5 yrs
56 (20.4)
5–10 yrs
60 (21.8)
>10
131 (47.6)
Mean (SD): 8.4 (2.1)
<500 mg
Daily medication Dose*
170 (61.8)
500–1000 mg
82 (29.8)
>1000mgs
23 (8.4)
Mean: 462 mg
One
Number of Antipsychotics Two
Three or more
*In Chlorpromazine equivalents.
97 (35.3)
152 (55.3)
26 (9.4)
studies [8,10,18]. Considering the finding that the mean
age (39.5 years) of the respondents fell within the reproductive age group, problems with their sexual functioning may be a significant source of concern for them with
far reaching consequences if left untreated.
Most of the patients (64.7%) in this study were taking
more than one conventional antipsychotics, an observation also made in a study examining the prescribing habits for psychiatric in-patient admissions [23]. Other authors
have found that despite extensive research and recommendations regarding the rational prescription of antipsychotic drugs, polypharmacy exists even among clinically
stable patients [24].
This study reports an association between poly-pharmacy
and sexual dysfunction which can be explained by the fact
that increasing the number of medications result in
increased risk of adverse effects experienced by patients.
Our finding is similar to what previous authors reported
that combination of antipsychotics adds to the risks of
developing medication side effects [25]. In addition, we
found a significant relationship between medication
dosages (chlorpromazine equivalents) and some forms of
sexual dysfunction, similar to that reported by some
authors [7]. Higher dosages of conventional antipsychotics are therefore associated with higher prevalence of
sexual dysfunction since there will be more drugs to act
at the various pathways leading to sexual dysfunction [8].
Among the conventional antipsychotics medications
prescribed, only haloperidol showed a significant relationship with sexual dysfunction (erectile and orgasmic
dysfunctions). This may be attributed to the high affinity
of haloperidol for dopamine D2 receptor and inhibition
of dopamine release, resulting in impaired libido and
erection [26]. On the other hand, the sexual dysfunction
observed may be a result of severe psychopathologies
experienced by the patients [4], which then necessitated
the use of a highly potent typical antipsychotic medication like haloperidol.
Erectile dysfunction was the commonest type of sexual
dysfunction reported by the respondents, a finding also
reported in previous studies [19,27,28]. Poor penile erection interferes with subjective enjoyment of other stages
of sexual intercourse and because it was the commonest
sexual dysfunction reported by respondents, it may account for the high prevalence of intercourse dissatisfaction and overall dissatisfaction with sex observed in this
sample. Inability to achieve good penile erection for optimal sexual satisfaction may be associated with feelings
of inadequacy in the sufferer. In many societies, including Nigeria, individuals with poor or absent penile erection are often stigmatized, subjected to public ridicule
and may be deserted by their spouse. Erectile dysfunction may result in poor treatment adherence and negatively impacts on patients’ quality of life [15].
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Table 2 Association between Specific Sexual dysfunctions and Sociodemographic, Illness-related and Medicationrelated Variables
VARIABLES OPTIONS
Sexual Desire
Erectile
Orgasmic
Dysfunction
Dysfunction
Dysfunction
χ2, df,
(p -Value)
χ2, df,
(p -Value)
χ2,df,
(p -Value)
Intercourse
Overall
Dissatisfaction Dissatisfaction
χ2,df,
(p -Value)
χ2,df,
(p -Value)
Sociodemographic
Age Group
<30 yrs/31–40 yrs/41–50 yrs/
51–60 yrs
4.330, 3, (0.228)
4.581, 3, (0.205)
9.231, 3, (0.026) 5.111,3, (0.164)
3.514, 3, (0.319)
Age at Onset of Illness
<15 yrs/15–25 yrs/26–35 yrs/
>35 yrs
1.997, 3, (0.573)
1.329, 3, (0.722)
2.635, 3, (0.451)
1.435, 3, (0.697)
0.688, 3, (0.876)
Marital Status
Married/Single/Separated/Divorced/ 1.653,4, (0.799)
Widowed
5.332, 4, (0.255)
6.084, 4, (0.193)
8.543, 4, (0.074)
12.067, 4,(0.017)
Level of Education
Nil/Primary/Secondary/Tertiary
5.659, 3, (0.129)
1.709, 3, (0.635)
2.718, 3, (0.437)
5.281,3, (0.152)
0.106, 3, (0.991)
Employment Status
Employed/Unemployed
9.087, 1, (0.003) 2.334, 1, (0.092)
9.852, 1, (0.002) 4.259, 1, (0.039) 4.696, 1, (0.030)
Duration of
Medication Use
<2 yrs/2–5 yrs/6–10 yrs/>10 yrs
1.013, 3, (0.798)
1.566, 3, (0.667)
2.343, 3, (0.504)
1.794, 3, (0.616)
6.215, 3, (0.102)
Number of
Medications
One/Two/Three or more
3.537, 2, (0.171)
4.506, 2, (0.105)
1.960, 2, (0.375)
0.687, 2, (0.709)
3.390, 2, (0.184)
Medication Related
Haloperidol
Yes/No
0.697, 1, (0.404)
4.979, 1, (0.026) 4.620, 1, (0.032) 1.041, 1, (0.308)
3.145, 1, (0.076)
Chlorpromazine
Yes/No
0.041, 1, (0.713)
0.053, 1, (0.818)
0.000, 1, (1.000)
0.136, 1, (0.712)
0.005, 1, (0.943)
Thioridazine
Yes/No
0.000, 1, (1.000)
0.547, 1, (0.460)
0.618, 1, (0.432)
0.084, 1, (0.772)
0.014, 1, (0.907)
Trifluoperazine
Yes/No
0.000, 1, (1.000)
0.000, 1, (1.000)
0.116, 1, (0.733)
0.003, 1, (0.956)
0.036, 1, (0.850)
Fluphenazinedecanoate Yes/No
1.164, 1, (0.281)
1.357, 1, (0.244)
0.000, 1, (1.000)
0.007, 1, (0.933)
0.815, 1, (0.367)
Flupenthixoldecanoate
Yes/No
0.181, 1, (0.671)
0.000, 1, (1.000)
0.246, 1, (0.620)
0.000, 1, (1.000)
0.000, 1, (1.000)
<500 mg/500 mg-1000 mg/
>1000 mg
5.179, 2, (0.075)
6.851, 2, (0.033) 7.094, 2, (0.029) 4.197, 2, (0.123)
*
Dose of Medication
6.929, 2, (0.031)
Illness Related
Diagnosis†
Schiz/PDD/APD/SZA/UPD
2.149, 4, (0.708)
4.769, 4, (0.312)
3.015, 4, (0.555)
6.669, 4, (0.154)
1.943, 4, (0.746)
Any Psychopathology
on BPRS
Present/Not Present
2.293, 1, (0.130)
0.031, 1, (0.860)
0.075, 1, (0.784)
0.000, 1, (1.000)
5.056, 1, (0.025)
*
Chlorpromazine Equivalents;
Schiz – Schizophrenia; PDD – Persistent Delusional Disorder; APD – Acute Psychotic Disorder; SZA – Schizoaffective Disorder; UPD – Unspecified Psychotic
Disorder.
BPRS – Brief Psychiatric Rating Scale.
Variables having significant association with any form of sexual dysfunction are in bold.
†
Our study revealed a significant relationship between
marital status and sexual dysfunction, specifically with
overall dissatisfaction with sex. It may be that patients
with medication induced sexual dysfunction were likely
to be dissatisfied with their overall sexual functioning.
For married men, the marriage setting provides an opportunity for a ‘feedback’ from the spouse about sexual
performance, which may result in subjective awareness
of an existing sexual inadequacy, otherwise unnoticed by
the patient. This raises a possibility that the relationship
between marital status and sexual dysfunction seen in
these patients may be psychogenic in origin, rather than
organic. Unfortunately, the IEFF could not distinguish
between organic and psychogenic sexual dysfunction, an
important limitation of this study. However, other
authors have also reported a significant association between marital status and sexual dysfunction among
patients taking conventional antipsychotics in Nigeria [19]
In this study, unemployed respondents were more
likely to have sexual dysfunction than those who are
employed. Previous studies have found an association
between sexual dysfunction, depression and socioeconomic disadvantages like unemployment [8,29]. Unemployment may result in role reversal within a relationship,
engendering feelings of shame and inadequacy in the male
partner. Previous authors have reported that unemployment in a person with mental illness is associated with
public and self-stigmatization, a “double jeopardy”, which
may negatively impact on self-worth and sexual performance or satisfaction [21].
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Page 6 of 7
This study has a number of limitations. First, it was
cross-sectional in nature, so the direction of causality
between sexual dysfunction and the sociodemographic
and clinical variables could not be inferred from the
findings. Second, there is a limitation regarding the generalizability of the result to other patients on conventional antipsychotics in Nigeria, as the study was
conducted in just one centre. Third, the absence of a
control group is also an important limitation to the
generalizability of our results. However, to the best of
our knowledge, it is the first to examine sexual dysfunction among specific group of psychiatric outpatients on
conventional antipsychotics in Nigeria. It is also one of
the few available studies on sexual dysfunction in a developing country setting where conventional antipsychotic
medications are commonly prescribed for the treatment
of psychotic illnesses [30].
4.
Conclusions
Sexual dysfunction is common among outpatients with
psychotic disorders on conventional antipsychotics. It is
associated with demographic, illness and medication related variables. Unemployment was found to be the most
important independent correlate of sexual dysfunction.
Therefore, there is a need among clinicians for increased
awareness and recognition of the sexual side effects of
conventional medications on patients, especially those
socially disadvantaged. This should guide antipsychotic
medication prescription resulting possible improvement
in treatment adherence and outcome.
12.
Competing interests
The authors declare that they have no competing interests.
5.
6.
7.
8.
9.
10.
11.
13.
14.
15.
16.
17.
18.
19.
Author details
1
Neuropsychiatric Hospital, Aro, P.O Box 2210, Sapon, Abeokuta, Ogun State,
Nigeria. 2Ladoke Akintola University Teaching Hospital, Ogbomoso, Oyo
State, Nigeria.
20.
21.
Authors’ contribution
OAK conceived the study and together with ATO designed the study. OAK
executed the data collection. AOA and OA did the statistical analysis and
drafted the first version of the manuscript. OAK and ATO participated in the
interpretation of data. All authors read and approved the final manuscript.
22.
23.
Source of financial support
None.
24.
Received: 28 March 2012 Accepted: 28 May 2012
Published: 7 June 2012
25.
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doi:10.1186/1756-0500-5-267
Cite this article as: Oyekanmi et al.: Demographic and clinical correlates
of sexual dysfunction among Nigerian male outpatients on
conventional antipsychotic medications. BMC Research Notes 2012 5:267.
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